Proactive Care (Berkshire West) - Frailty

Description

Proactive care relating to frailty in West Berkshire commencing Autumn 2026 to deliver improved outcomes from Winter 2026. Lot 1: Berkshire Healthcare NHS Foundation Trust is seeking a provider to undertake proactive care relating to frailty with the intention of keeping patients out of an acute hospital setting. This service will operate from November 2026 and run to 30th September 2027. The provider will deliver a targeted Proactive Neighbourhood Service for an agreed cohort drawn primarily from PNG groups 10-11 and, where clinically appropriate, selected patients within PNG 9. They will operate as part of the wider Berkshire West neighbourhood and Integrated Neighbourhood Team model, working alongside primary care, community services, social care, mental health, therapy and specialist services. They will identify and prioritise the agreed cohort using population health data, clinical judgement, frailty indicators and local intelligence and undertake proportionate, frailty-focused holistic assessment based on clinical need, including a mini-CGA or equivalent structured assessment where appropriate. They will: (1) Refer patients with complex or specialist needs into the appropriate multidisciplinary, community, frailty or specialist pathway; (2) Review, develop or update care plans where clinically indicated, including crisis planning, advance care planning, end-of-life planning and ReSPECT documentation where appropriate; (3) Present or refer patients to the relevant core cluster MDT, specialist MDT or neighbourhood forum where multidisciplinary input is required; (4) Participate in regular MDT meetings and shared decision-making to support coordinated care; (5) Work with system partners to improve alignment and coordination of existing services within the Berkshire West neighbourhood model; and (6) Maintain continuous review of high-risk cohorts to support proactive, targeted intervention.